MEDICARE: DR. LEROY SOUTHMAYD III M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician	17164	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851351969
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEROY SOUTHMAYD III M.D.

Provider Business Mailing Address
First Line	:	1202 W WILSHIRE BLVD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-6109
Country	:	US
Telephone Number	:	405-823-3073
Fax Number	:

Provider Business Practice Location Address
First Line	:	1202 W WILSHIRE BLVD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-6109
Country	:	US
Telephone Number	:	405-823-3073
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2006
Last Update Date	:	03/08/2020

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